Pediatric Coding Alert

Question: A new patient presented in our office. Our pediatrician documented a comprehensive history of present illness (HPI) and conducted a complete review of systems (ROS). The resulting diagnosis was of a moderate complexity and involved data management. Other than the provider taking the patient’s vitals, there was no physical exam. What evaluation and management (E/M) level can I document in this situation? Can I bill a level-4 new patient encounter in this situation?

Ohio Subscriber

Answer: CPT^® regulations require all three components — history, examination, and decision making —for a new patient E/M service. The encounter you describe satisfies the history and decision-making requirements for 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity …).

What’s missing in this situation is an exam component commensurate with a level-4 encounter, and no matter which of the two different Centers for Medicare and Medicaid (CMS) guidelines you use, using the patient’s vitals for the exam component does not meet the criteria for billing 99204.

1995 guidelines count vitals as one organ system (“Constitutional [e.g., vital signs, general appearance]”). As a level-4 encounter under these guidelines requires “a general multi-system examination or complete examination of a single organ system,” and this encounter only features a limited exam of one organ system, the exam element of this encounter would only rise to the level of a problem-focused exam.

1997 guidelines count “measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight” as one bullet. You have to document fourteen bullets for the comprehensive exam needed for a level-4 new patient E/M. But as this is only one element, it would again only rise to the level of a problem-focused exam (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).

So, as CPT^® states “all of the key components … must meet or exceed the stated requirements to qualify for a particular level of E/M services,” and as the exam component does not rise any higher than a problem-focused exam, you must code the service you describe as 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …).

However, if your provider documented the total amount of time spent in the visit, and if that provider spent more than 50 percent of that time counseling the patient and no exam was warranted, then you could bill the visit based on time as the key factor.

For example, the E/M visit level could rise to 99203 (Office or other outpatient visit for the evaluation and management of a new patient … Typically, 30 minutes are spent face-to-face with the patient and/or family) if the total amount of time for the visit was 26 minutes or 99204 if the total amount of time for the visit was 38 minutes. That would give you a much higher reimbursement rate than 99201 for the work performed by your pediatrician.

Remember when using time as a key factor, you do not have to take into consideration the history, exam, or MDM.